MEDICARE: LISA PENCE L.I.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-2538	NM

General Provider Information

NPI Number	:	1912913674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PENCE L.I.S.W.

Provider Business Mailing Address
First Line	:	PO BOX 22960
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87502-2960
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1444 S SAINT FRANCIS DR # C
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4038
Country	:	US
Telephone Number	:	505-982-8228
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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